n00256 Recredentialing Process Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The purpose of recredentialing is to assure that Network Health Plan/Network Health Insurance Corporation/Network Health Administrative Services, LLC (NHP/NHIC/NHAS) practitioners' show continued competence by education, experience and continued commitment to high quality, cost effective medical care for continued participation in NHP/NHIC/NHAS. Policy Detail: I. POLICY: Recredentialing is conducted in a manner that does not discriminate on the basis of race, ethnicity, ethic/national identity, gender, age, religion, sex, sexual orientation or the type of procedure or patient in which the practitioner specializes or serves. A complete review will be conducted on every file that is denied by the credentials committee to ensure that the denial was non-discriminatory. The Medical Director or Designated Physician will appoint a peer to review the denial to ensure that the decision was made in a non-discriminatory manner. The specific steps that the organization uses to prevent and monitor discriminatory practices are as follows: Upon credentialing and/or recredentialing, the Medical Director or Designated Physician attests that the file review was conducted in a non-discriminatory manner and makes a recommendation to the Centralized Credentials Committee. The results of such review will be reported back to the Credentials Committee by the Medical Director or Designated Physician. Practitioners shall be notified within 60 calendar days of the committee s Recredentialing decision. Practitioners have the right, upon request, to be informed of the status of their recredentialing application. Review of information to evaluate continued participation of practitioners is ongoing and periodic. In situations where there is a question regarding any primary source verification or quality issue or if requested by the Credentialing Committee, additional investigation or review may be initiated. This policy applies to all practitioners including PPO practitioners when applicable (see related document NHP/NHIC/NHAS PPO "When Applicable" Definition). This policy is consistent with NHP/NHIC/NHAS's mission, vision and values. All credentialed NHP/NHIC/NHAS practitioners as identified in the Credentialing Process must successfully complete the recredentialing process within a 36 month timeframe for a continued contract as a NHP/NHIC/NHAS practitioner.
However, practitioners whose credentialing or recredentialing required special consideration by the Credentials Committee are required to be reevaluated on an annual basis (every 12 months) or as determined by the Credentials Committee. (See Range of Actions to Improve Performance/Altering the Conditions of Participation). All recredentialing applications will be returned to the NHP/NHIC Credentialing Department no later than 90 days of receipt of recredentialing application. Only practitioners who are currently credentialed are included in the NHP/NHIC/ NHAS Provider Directory. Education, training and certification relevant to each specialty/subspecialty in which a practitioner desires to practice will be assessed with each recredentialing cycle. If a practitioner desires to change his/her specialty/ subspecialty between recredentialing cycles, this change would need to be presented to the Credentialing Committee for approval. No practitioner will be listed individually by name in NHP/NHIC/NHAS s Directory unless they have been approved by the committee for their specialty or subspecialty of practice. All listings in provider directories and other member materials shall be consistent with credentialing data, including education, training, certification, and specialty. Processes to ensure consistency include (a) obtaining complete information regarding education, training, certification, and specialty for each specialty or subspecialty in which the practitioner intends to practice, (b) auditing the accuracy of credentialing information in the Echo database, which is the source of provider directory information. Procedure Detail: I. PROCEDURE: A. Recredentialing Data Collection and Primary Source Verification: 1. The Network Health Credentialing Department collects recredentialing data and conducts primary source verification. The NHP/NHIC/NHAS recredentialing application and verification process is outlined in the Recredentialing Information Collection/Coordination/Dissemination policy and procedure (http://policy.networkhealth.com). Completed recredentialing applications are required to be completed in via handwritten or electronic documentation. Faxed, digital, scanned or photocopied signatures are acceptable. Signature stamps are not acceptable. Electronic signatures must be generated from a secure site. Handwritten signatures will be recorded in black or blue non-erasable, non-water soluble ink, felt tip markers, fountain pens and signature stamps may not be used. In so doing, completed recredentialing applications will be forwarded to the Credentialing Department for assessment and are considered by the Medical Director or Designated Physician and/or the Credentials Committee. Information and verification is to be no more than 180 calendar days old at the time of review and decision by the Medical Director or Designated Physician and/or the Credentials Committee. 2. Documentation Process: a. Actual copies of credentialing information are kept within the file or electronically. b. The name of the source used, the date of verification, the signature or initials of the person who verified the information - 2 -
and the report date, if applicable, are included on a detailed/signed checklist to be kept in the file or electronically. c. An electronic signature or unique electronic identifier of staff is used to document verification. The electronic signature or unique identifier can only be entered by the signatory. The system identifies the individual verifying the information, the date of verification, the source and the report date, if applicable. B. Confidentiality: 1. All recredentialing information received and all recredentialing files, minutes, reports and any other material used to determine a recredentialing decision is confidential and stored in a secure area in the Credentialing Department. Disclosure of such information will not be granted unless a consent for release of information has been signed by the applicant. C. Practitioner Notification: 1. The recredentialing application includes a statement that notifies the practitioner of his/her right to review information obtained by NHP/NHIC/ NHAS to evaluate their recredentialing application. This evaluation includes information obtained by any outside primary source (e.g., malpractice insurance carriers, state licensing boards). A practitioner is not allowed to review references or recommendations or other information that is peer review protected. 2. The recredentialing application also notifies the practitioner of his/her right to correct erroneous information obtained from other sources that varies substantially from that provided by the practitioner, e.g. actions on a license, malpractice claims history or board certification decisions. Practitioners are informed of their right to request the status of their application. Request for information on the status of the application should be made through the Credentialing Department via e-mail or phone call. This right is found on the attestation page of the application. The Credentialing Department will notify the practitioner by e-mail, mail, or fax within ten (10) calendar days of receipt of information and this notification will be documented in the practitioner's credentials file. The Credentialing Department is not required to reveal the source of information if the information is not obtained to meet the requirements of the credentialing verification requirements or if disclosure is prohibited by law. The practitioner will be given ten (10) calendar days to correct erroneous information submitted by another party. Corrections and/or additional information to the application must be submitted in writing to the Credentialing Department via e-mail or mail to NHP/NHIC/ NHAS Credentialing Department, 1570 Midway Place, Menasha WI 54952 and the receipt of such will be documented and retained in the practitioner's credentials file. The Credentialing Coordinators will communicate via e-mail to schedule arrangements with practitioner either electronically, mail, or in person in the Credentialing Department. D. Process for Ongoing Monitoring of Sanctions, Complaints, Adverse Events and Quality Issues: 1. NHP/NHIC/NHAS monitors for sanctions and tracks complaints and quality issues against practitioners throughout the 36 month time frame - 3 -
between formal recredentialing. This is consistent with the NHP/NHIC/ NHAS's mission, vision and values. This is done through monthly queries and reports from the Office of the Inspector General, the State of Wisconsin Department of Safety and Professional Services and NHP/ NHIC/NHAS's Complaint Database and Proactive Disclosure Service (PDS). This process is done on an automatic continuous monitoring basis with reports from the NPDB/HIPDB. This process means that as new information is received on an enrolled practitioner NHP/NHIC/NHAS's Medical Director or Designated Physician is alerted and appropriate action is taken in accordance with related NHP/NHIC/NHAS polices. Also queried on a quarterly basis is the Medicare Opt Out Report. Findings of sanctions are reported to the Credentials Committee. Significant quality of care issues are reviewed by the Peer Review Committee which submit biannual reports to the Credentialing Committee for review and discussion. A corrective action plan is approved by the Committee as appropriate. E. Approval Process: 1. The decision to retain or not retain a current practitioner is based on the information available, including but not limited to the information gathered through a completed recredentialing application and the verification of all collected information. Sanctions, complaints, adverse events and quality information are also used to evaluate the current practitioner. See Process for Ongoing Monitoring of Sanctions, Complaints, Adverse Events and Quality Issues. Recredentialing criteria is used to establish consistent, clear objectives for the recredentialing of current practitioners. The following criteria are prerequisites for consideration by the Credentials Committee for continued participation as a practitioner of NHP/NHIC/ NHAS. F. Recredentialing Criteria: 1. General Credentialing Criteria: a. To be credentialed, and recredentialed within NHP/NHIC/NHAS for a specialty/subspecialty, all physicians, podiatrists, dentists and other practitioners must meet one of the following: i. Must have obtained board certification within 5 years of residency completion. Current board certifications are recognized if awarded by the following: a) ABMS, AOA, American Board of Podiatric Surgery, American Board of Foot & Ankle Surgery (ABFAS) or Dental Specialty Certifying Board OR if within 5 years post residency the applicant must meet the criteria for admission to the examination of such a certifying board in the specialty or subspecialty in which the practitioner intends to practice. -Orb) Documented satisfactory training/experience equivalent or equal to board certification or documented years of quality service in the - 4 -
specialty or subspecialty, colleague support, and proof of CME per review at Credentials Committee and affirmed by a ¾ majority vote of Credentials Committee practitioners who are present at the meeting. G. Additional Recredentialing Criteria for Physicians (M.D. and D.O.) 1. Must continue to hold a current, valid, unencumbered license to practice Medicine and Surgery in the State of Wisconsin. A license is unencumbered if it has not been subject to any adverse action, including but not limited to probation, suspension, revocation, imposition of conditions such as supervision of periodic reporting, restrictions of nature of scope of practice, or public, or private censure. 2. Must continue to hold a current unrestricted Federal Drug Enforcement Agency (DEA) or Controlled Dangerous Substances (CDS) certificate if applicable and with a State of Wisconsin Address or an explanation why the practitioner does not prescribe medications and must provide arrangements for the practitioner's patients who need prescriptions for medications requiring DEA and CDS certification. 3. Must hold current malpractice coverage in which coverage pertains to area of practice or profession and meets the minimum limit requirement as specified by the Wisconsin Department of Regulations and Licensing. Must be current with Wisconsin Patient Compensation Fund assessments. 4. Must continue to show absence of a history of professional liability claims including, but not limited to, lawsuits, arbitration, settlements or judgments; or must show evidence that history of professional liability claims does not demonstrate probable future substandard professional performance. 5. Must continue to show absence of history of denial or cancellation of professional liability insurance or, must show evidence that history of denial or cancellation of professional liability insurance does not demonstrate probable future substandard professional performance. 6. Must continue to hold current clinical privileges, in good standing, at a plan hospital; or must show evidence that the applicant does not require hospital privileges in order to deliver satisfactory professional services, i.e., practicing in immediate care service only. If plan hospital privileges are not held and practitioner may potentially have the need to admit patients, the practitioner must have a current written formal inpatient coverage arrangement agreed by contracted NHP/NHIC/NHAS practitioner(s). 7. Must show absence of history of loss or limitation of privileges or disciplinary activity by a hospital or other health care facility or, must show evidence that history of loss or limitation of privileges does not demonstrate probable future substandard professional performance. 8. Must continue to show absence of history of any professional disciplinary action or sanctions by federal, state and local authorities, including each jurisdiction in which the practitioner practices or previously practiced to include, but not limited to: a. Being placed on probation, reprimanded, fined or having medical practice restricted by any agency that disciplines practitioners. - 5 -
b. Medicare or Medicaid reprimand, censure, disqualification, suspension or have voluntarily opted out. c. Conviction of or indictment for a felony. In the case of such history, must show evidence that this history does not demonstrate probable future substandard professional performance or probable future unacceptable business practices. 9. Must continue to show absence of a chemical dependency or substance abuse problem that might adversely affect practitioner's ability to competently and safely perform the essential functions of a practitioner in the same area of practice and practitioner shows absence of physical or mental condition that may impair the practitioner's ability to practice within the full scope of licensure and qualifications, or may pose a risk of harm to patients. (See Range of Actions to Improve Performance/Altering the Conditions of Participation) 10. The Absence of falsification of the recredentialing application or material omission of information requested in the application. 11. Specific criteria for practitioners other than M.D.'s and D.O.'s are listed as Specific Recredentialing Criteria to this policy. (See related document.) 12. The application, attestation and primary source verification information is to be no more than 180 calendar days old at time of the recredentialing decision. If application/attestation becomes older than 180 calendar days, the application is to be returned to the practitioner for any updates and a new attestation form is to be signed and dated by the practitioner attesting that the application is correct and complete. If primary source verification becomes older than 180 calendar days, the information will be re-verified by the primary source. State license, DEA certificate, and malpractice insurance policy must be current at time of recredentialing decision. 13. Once the complete recredentialing application and primary source information has been assessed against the established criteria, the recredentialing application and file is forwarded to the Medical Director or Designated Physician. The Chairperson will review the Recredentialing file determine whether it meets recredentialing criteria, and recommend the practitioner's approval for continued participation to the Credentials Committee at the next scheduled meeting or to pend recommendation for further review and discussion by the Credentials Committee. 14. A summary of all recredentialing applications will be presented at the Credentials Committee meeting. Any recredentialing files of practitioners will be made available and can be reviewed upon request at the Credentials Committee meeting. The Credentials Committee may accept the recommendations made by the Chairperson or pend for further review and discussion. The final recredentialing decision will be made by the Credentials Committee. In the instance of providers who fail to meet all recredentialing criteria, the Credentials Committee may approve, request submission of an action plan for improvement by the practitioner, limit recredentialing with further review, or terminate. 15. Recredentialing decisions shall be documented in the practitioner's file and the Credentials Committee meeting minutes. - 6 -
16. The Credentialing Department will notify the practitioner of the recredentialing decision by letter. If a practitioner is terminated for, if, and only if, reasons related to quality of care, competence and professional conduct, NHP/NHIC/NHAS will inform the practitioner of his/her right to a fair hearing/appellate review and may be required to report such findings to the State of Wisconsin Department of Safety and Professional Services, the National Practitioner Data Bank. (See Range of Actions to Improve Performance/Altering the Conditions of Participation, Fair Hearing and Appellate Review Process, and Reporting to Proper Authorities). 17. NHP/NHIC/NHAS Board of Directors has delegated accountability for credentialing/recredentialing decisions to the Credentials Committee, the Credentials Committee reports to the Quality Management Committee (QMC). In the case of an appeal, the Board of Directors makes the final decision. The Medical Director or Designate Physician is ultimately accountable for the credentialing program and serves as a member of the Credentials Committee. The Medical Director reports through the QMC to the Board of Directors on all recredentialing activities. 18. The recredentialing application and supporting documents must be kept as a permanent record in the Credentialing Department. The credentialing files on a participating practitioner are retained throughout the time period that the contract with NHP/NHIC/NHAS remains effective. They are kept for a minimum of ten years after the date of contract termination. The identity of terminated practitioners will also be retained. H. Participation Reinstatement of Practitioners Who Terminated With NHP/NHIC/ NHAS 1. If a practitioner was successfully credentialed/recredentialed by NHP/ NHIC/NHAS, leaves NHP/NHIC/NHAS, and then NHP/NHIC/NHAS or the practitioner wants to reinstate participation in NHP/NHIC/NHAS, the following procedure will be conducted: a. Practitioner will review and update most current application to include any additional training/work history and explanation of any gaps from time practitioner left NHP/NHIC/NHAS to present. b. Practitioner will sign and date attestation form attesting that updated application is complete and correct. c. The Credentialing Department will ensure that all previously verified information is still correct and will re-verify any time limited information. d. The complete application, attestation, and primary source information will be assessed against NHP/NHIC/NHAS recredentialing criteria and forwarded to the Credentials Committee Chairperson for review and recommendation. e. A summary of the practitioner's reapplication will be presented to the Credentials Committee, along with the recommendation by the Chairperson. The Credentials Committee shall make the final decision on the practitioner's participation in NHP/NHIC/NHAS. f. The practitioner must complete the above process before a contract is executed. - 7 -
2. If leave extends beyond the next scheduled recredentialing cycle, the practitioner will need to complete a credentialing application and complete the credentialing process before a contract is executed. 3. If either party terminated the contract or there is a break in service of more than 30 calendar days, the organization must initially credential the practitioner. 4. If the practitioner cannot be recredentialed within 36 month timeframe because the practitioner is an active military assignment, maternity leave or a sabbatical, but the contract between NHP/NHIC/NHAS and the practitioner remains in place, NHP/NHIC/NHAS may recredential the practitioner upon his or her return and will document the reason the delay in the practitioner's file. At a minimum, NHP/NHIC/NHAS will verify that a practitioner who returns from military assignment, maternity or a sabbatical has a valid license to practice before he or she resumes seeing patients. Within 60 calendar days of when the practitioner resumes practice, NHP/NIC will complete the recredentialing cycle. On the other hand, if either party terminates the contract or there is a break in service of more than 30 calendar days, NHP/NHIC/NHAS will initially credential the practitioner before the practitioner rejoins the network. NHP/NHIC/NHAS will recredential the practitioner as long as it provides documentation that the practitioner was terminated for reason beyond its control and was recredentialed and reinstated within 30 calendar days of termination. NHP/NHIC/NHAS will initially credential the practitioner if reinstatement is more than 30 calendar days of termination. Definitions: None Regulatory Citations: None Related Policies: n00264 - Range of Actions to Improve Performance/Altering the Conditions of Participation n00255 - Process for Ongoing Monitoring of Sanctions, Complaints, Adverse Events and Quality Issues Related Documents: Network_Health_Plan_PPO_Definitions.pdf Origination Date: 08/01/1996 Approval Date: 05/24/2018 Next Review Date: 05/01/2019-8 -
RegulatoryBody: Approving Committee: NCQA, CMS Credentials Committee Policy Owner: Department of Ownership: Andrea Albright Credentialing Revision Reason: 5/24/2018-Updated Board Certification waiver documentation requirement 11/14/2016-Updated verbiage re: Board Cert. 10/18/2016-Updated policy owner. 08/18/2016-Transferred to new policy template. Policy Entity: NHP/NHIC/NHAS Revision Number: 4-9 -